Healthcare Provider Details

I. General information

NPI: 1659076420
Provider Name (Legal Business Name): KELLY ANN LYDICK CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2023
Last Update Date: 04/03/2023
Certification Date: 04/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2336 ARDMORE BLVD
PITTSBURGH PA
15221-5202
US

IV. Provider business mailing address

100 OAKDALE RD
NORTH VERSAILLES PA
15137-1903
US

V. Phone/Fax

Practice location:
  • Phone: 412-273-3487
  • Fax:
Mailing address:
  • Phone: 412-378-2071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number22011020352331
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: